Join a virtual action learning set ALS Application Form Step 1 of 6 16% Application IDPrivacy AgreementBy completing this form you agree to our Privacy Policy. This includes using your personal data to contact you about the offer.*By completing this form you agree to our Privacy Policy. This includes using your personal data to contact you about the offer. I agree to the Privacy Policy Your Contact Details Information: Why do we ask this?Your contact details allow us to provide you with a response and connect you with a group facilitator.Name* First Last Email* Phone* Your Work Details Information: Why do we ask this?Your work details allow us to group you with people from the same organisation, when relevant, and to monitor the reach of this offer.Region*Which NHS region are you in?— SELECT REGION —East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestOtherSTP*Which sustainability and transformation partnership do you work for?— SELECT STP —Bath, Swindon and WiltshireBirmingham and SolihullBristol, North Somerset and South GloucestershireBuckinghamshire, Oxfordshire and Berkshire WestCambridgeshire and PeterboroughCheshire and MerseysideCoast, Humber and ValeCornwall and the Isles of ScillyCoventry and WarwickshireDerbyshireDevonDorsetDurham, Darlington, Tees, Hambleton, Richmondshire and WhitbyFrimley HealthGloucestershireGreater ManchesterHampshire and the Isle of WightHerefordshire and WorcestershireHertfordshire and West EssexKent and MedwayLancashire and South CumbriaLeicester, Leicestershire and RutlandLincolnshireMid and South EssexMilton Keynes, Bedfordshire and LutonNorfolk and WaveneyNorth Central LondonNorth East LondonNorth West LondonNorthamptonshireNorthumberland, Tyne & WearNottinghamshireShropshire and Telford and WrekinSomersetSouth East LondonSouth West LondonSouth Yorkshire and BassetlawStaffordshireSuffolk and North East EssexSurrey HeartlandsSussex and East SurreyThe Black CountryWest Yorkshire and HarrogateWest, North & East CumbriaNot ApplicableOrganisation*What is the official name of the primary organisation you work for? Job Title*What is your main job title? Learning Set Choice Information: Why do we ask this?These details help us allocate you to an appropriate action learning set. Preferred ALS type*Please select which type of action learning you prefer Regional and system focus National level Equality diversity and inclusion focus Strategic focus on recovery for Chairs Regional and system focus A specific ‘local leadership system’ – where you will be challenged to work within the context of both your ‘real-work’ and your ‘real-time working relationships’. National level A general ‘national leadership network’ from across the entirety of the NHS system – where you will be challenged to work within the context of their ‘real work’ by connecting through broader, less-localised leadership networks. Equality diversity and inclusion focus A group of colleagues across health and care specifically interested in exploring and deepening learning around equality, diversity and inclusion and racial justice. Reason for Applying Information: Why do we ask this?We will use your response to this question to prioritise the limited places available and determine the right group for your needs. Reason*Please explain why would you like to focus on an Action Learning Set at this moment in time and why you have chosen the type of set you selected on the previous page. You should not disclose any personally identifiable data in this response. Protected Characteristics Information: Why do we ask this? We use this information to ensure learning sets have a diverse membership and to monitor our inclusive access. What is your approximate age?*— SELECT AGE RANGE —Under 1818-2425-3435-4445-5455-6465 or AboveI do not wish to discloseDo you consider yourself to have a disability?* Yes No I do not wish to disclose Disability categories*Please identify the category or categories that apply to you, or choose other type of disability. Learning disability/difficulty Long-standing illness Mental Health Condition Not declared Physical Impairment Sensory Impairment Other Are you now or have you ever defined yourself as Trans?* Yes No I do not wish to disclose Which of the following best describes your ethnic background?*— SELECT ETHNIC ORIGIN —White BritishWhite IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundChineseAny Other Ethnic GroupI do not wish to discloseWhich of the following best describes your religion or belief system?*— SELECT RELIGION —AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismOtherNot religiousI do not wish to discloseWhich of the following best describes your gender?* Female Male Another gender I do not wish to disclose Which of the following best describes your sexual orientation?*— SELECT SEXUAL ORIENTATION —AsexualHeterosexual or StraightGay or LesbianBisexualOther sexual orientation not listedUndecidedI do not wish to discloseNationality*Please choose the (primary) country you officially belong to.— SELECT COUNTRY —United KingdomÅland IslandsAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweI do not wish to discloseWould you be happy to receive updates from the Leadership Academy about other offers?*YesNoHiddenLearning Set— SELECT LEARNING SET —– Fill Out Other Fields –HiddenReason for not approving application Executive leaders virtual action learning setsApply to join a Virtual ALS